1. Zurich 2012 – What’s new in Sport Concussion?
4th International Conference on Concussion in Sport held in Zurich, November 2012
© Concussion in Sport Group, 2013

2. OUTLINE Process Definitions Evaluation Management Modifying Factors
Special Populations
Other Issues
SCAT3, CRT, child SCAT3

3. 1. Process 1st Vienna 2001, 2nd Prague 2004, 3rd Zurich 2008
4th meeting in Zurich 2012
NIH consensus development conference format
Pre-defined group of questions
Body of literature identified
Presentation by experts in open session day 1 and day 2
Discussion / debate closed session with consensus panel on day 3
Document drafted by authors and circulated to panel
Knowledge translation

4. Expert Panel Identified for expertise and commitment to:
Author critical review papers (start April 2012)
Read all evidence prior to consensus meeting
Review all research abstracts at meeting
Attend all open lectures
Participate in closed panel discussion
Review and approve final consensus statement

5. Zurich 2012 Consensus Questions
What is the lowest threshold to make a diagnosis of concussion?
Are the existing tools/exam sensitive and reliable enough on the day of injury to make or exclude a diagnosis of concussion?
What is the best practice for evaluating an adult athlete on the "field of play" in 2012?
How can the SCAT2 be improved?: evidence for utility of components
What evidence exits for new strategies/technologies in the diagnosis of concussion and assessment of recovery?

6. Zurich 2012 Consensus Questions
Advances in the management of sport concussion: what is evidence for concussion therapies?
The difficult concussion patient - What is the best approach to investigation and management of persistent (>10 days) post concussive symptoms?
Revisiting Modifiers: how should the evaluation and management of acute concussion differ in specific groups?
What are the most effective risk reduction strategies in sport concussion?: from protective equipment to policy
What is the evidence for chronic concussion-related changes?; behavioral, pathological and clinical outcomes
From Consensus to Action- How do we optimize Knowledge transfer, education and ability to influence policy?

7. Expert Panel Members Scientific Committee:
Paul McCrory
Willem Meeuwisse
Mark Aubry
Robert Cantu
Jiri Dvorak
Ruben Echemendia
Lars Engebretsen
Karen Johnston
Jeffrey Kutcher
Martin Raftery
Allen Sills
Additional Panelists (alphabetical order)
Brian Benson
Michael Makdissi
Gavin Davis
Michael McCrea
Richard Ellenbogen
Amdrew McIntosh
Kevin Guskiewicz
David Maddocks
Stan Herring
Laura Purcell
Grant Iverson
Margot Putukian
Barry Jordan
Kathryn Schneider
James Kissick
Charles Tator
Michael Turner

8. Outputs: Co-publication multiple journals 2013 including: BJSM CJSM
with critical reviews
CJSM
J. Athletic Tr
J. Clin Neurosci
J. Sci & Med in Sport
PM&R
Scand J Sci Med Sport
S. African J. of Sport Med
J. Amer College of Surgeons

9. Outputs

10. Outputs All lectures on line www.f-marc.com
Free download of Statement & Tools
bjsm.bmj.com
Powerpoint presentation

11. 2. Definitions

12. Traumatic Brain Injury
Glasgow Coma Scale
“Minimal”
Mod
Severe
Mild ?
Sports concussion
Severe GCS ≤ 8
Moderate GCS
Mild GCS
Teasdale et al Lancet 1974; ii: 81-4

13. Injury Definition: Sports concussion
“Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include…”

14. Definition
Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an ‘‘impulsive’’ force transmitted to the head.
Concussion typically results in the rapid onset of short- lived impairment of neurologic function that resolves spontaneously. However in some cases symptoms and signs may evolve over a number of minutes to hours.
Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and as such, no abnormality is seen on standard structural neuroimaging studies.
Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However it is important to note that in some cases, post-concussive symptoms may be prolonged.

15. 3. Evaluation

16. Signs and Symptoms
Symptoms - somatic (e.g. headache), cognitive (e.g. feeling like in a fog) and/or emotional symptoms (e.g. lability)
Physical signs (e.g. loss of consciousness, amnesia)
Behavioural changes (e.g. irritability)
Cognitive impairment (e.g. slowed reaction times)
Sleep disturbance (e.g. drowsiness, insomnia)

17. On-field or sideline evaluation of acute concussion-when a player shows ANY features of a concussion
The player should be evaluated by a physician or other licensed healthcare provider onsite using standard emergency management principles and particular attention should be given to excluding a cervical spine injury.
The appropriate disposition of the player must be determined by the treating healthcare provider in a timely manner. If no healthcare provider is available the player should be safely removed from practice or play and urgent referral to a physician arranged.
Once the first aid issues are addressed an assessment of the concussive injury should be made using the SCAT3 or other sideline assessment tools.
The player should not be left alone following the injury and serial monitoring for deterioration is essential over the initial few hours following injury.
A player with diagnosed concussion should not be allowed to return to play on the day of injury.

18. Detailed clinical assessment outlined in SCAT3 and Child SCAT3
NOTE: Developed by SCAT3 Subcommittee (Meeuwisse, McCrory, Dvorak, Echemendia, Guskiewicz Iverson, Johnston, McCrea, Putukian, Raftery, Schneider)

19. Evaluation in emergency room or office by medical personnel
Individual clinical decision
A medical assessment including a comprehensive history and detailed neurological examination including a thorough assessment of mental status, cognitive functioning and gait and balance.
A determination of the clinical status of the patient including whether there has been improvement or deterioration since the time of injury. This may involve seeking additional information from parents, coaches, teammates and eyewitness to the injury.
A determination of the need for emergent neuroimaging in order to exclude a more severe brain injury involving a structural abnormality
In large part, these points above are included in the SCAT3 assessment

20. Investigations Neuroimaging (CT, MRI)
Contributes little to concussion evaluation
Use when suspicion of intracerebral or structural lesion exists:
focal neurologic deficit
worsening symptoms
Prolonged disturbance of conscious state
Other modalities such as fMRI correlate with symptom severity and recovery and although not routinely used presently may provide additional insight.
Alternative imaging technologies are still at early stage of development in concussion and not recommended other than research setting

21. Investigations
Postural stability testing-deficits 72hr post concussion
Balance error scoring system (BESS), force plate technology
Genetic testing/markers
Significance unclear for Apolipoprotein (Apo) E4, ApoE promoter gene, Tau polymerase, other genetic and cytokine factors
Insufficient evidence for routine clinical use

22. Investigations Neuropsychological (NP) assessment:
Important component in overall assessment and RTP
Should NOT be sole basis of management decisions, but an aid to clinical decision making
Included as part of clinical neurological assessment by treating physician often with computerized NP screening tools
Formal NP testing not required for all but, if so, interpretation should be performed by trained neuropsychologist.
Best done when asymptomatic but may be advantageous at other stages in particular situations
Baseline testing not mandatory. May be helpful in test interpretation and for education opportunity

23. 4. Management

24. Recovery Majority (80-90%) resolve in short (7-10 day) period
May take longer in children and adolescents

25. Management
CORNERSTONE = initial period of rest until acute symptoms resolve
Physical Rest
No training, playing, exercise, weights
Beware of exertion with activities of daily living
Cognitive Rest
No television, extensive reading, video games?
Caution re: daytime sleep

26. Management Expect gradual resolution within 7-10 days
Gradual return to school and social activities that does not result in significant exacerbation of symptoms
Proceed through step-wise return to sport / play (RTP) strategy

27. Recovered? Everyone “feels fine” Always ask:
1.“On a scale of 0 to 100%, how do you feel?”
2.“what makes you not 100%?”
3. Symptom Checklist – SCAT3

28. Graduated RTP Protocol
Rehabilitation stage
Functional exercise at each stage of rehabilitation
Objective of each stage
1. No activity
Symptom limited physical and cognitive rest.
Recovery
2.Light aerobic exercise
Walking, swimming or stationary cycling keeping intensity < 70% MPHR
No resistance training.
Increase HR
3.Sport-specific exercise
Skating drills in ice hockey, running drills in soccer. No head impact activities.
Add movement
4.Non-contact training drills
Progression to more complex training drills e.g. passing drills in football and ice hockey.
May start progressive resistance training
Exercise, coordination, and cognitive load
5.Full contact practice
Following medical clearance participate in normal training activities
Restore confidence and assess functional skills by coaching staff
6.Return to play
Normal game play
24 hours per step (therefore about 1 week for full protocol)
If recurrence of symptoms at any stage, return to previous asymptomatic level and resume after further 24 hr period of rest

29. Same day return to play? NO!
Unanimously agreed that no RTP should occur on the day of concussive injury

30. Return to Play / Sport Must pass graded exertion first
=remain asymptomatic
Is the athlete confident to go back?
New helmet/head gear?
Other “protective” equipment / behaviors / factors?
Consider implications of multiple/recent injury

31. “Difficult” or persistently symptomatic concussion patient
Persistent symptoms (>10 days) in about 10-15%
Important to consider other issues
Should be managed in multidisciplinary manner by healthcare providers experienced in sport concussion
In order to consider sub-symptom threshold exercise and other forms of therapy /rehabilitation

32. Psychological & Mental Health issues
Psychological approaches may have application especially in selected situations (modifiers)
Evaluate for affective symptoms (depression, anxiety) as common in all forms of traumatic brain injury
Depression-may be consequence of concussion, underlying pathophysiological abnormality, may be multifactorial but should be considered in management

33. Management Pharmacotherapy
Prolonged symptoms (sleep disturbance, anxiety)
Modify underlying pathophysiology
Upon return to play should not be on medication that could mask symptoms
Antidepressants?

34. 5. Modifying Factors

35. FACTORS
MODIFIER
Symptoms
Number
Duration (>10 days)
Severity
Signs
Prolonged LOC (>1min)
Amnesia
Sequelae
Concussive convulsions
Temporal
Frequency –repeated concussion over time
Timing – injuries close together
“Recency” – recent concussion or TBI
Threshold
Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion
Age
Child and adolescent (< 18 years old)
Co and Pre-morbidities
Migraine, depression or other mental health disorders, attention deficit hyperactivity disorder (ADHD), learning disabilities (LD), sleep disorders
Medication
Psychoactive drugs
Anticoagulants
Behaviour
Dangerous style of play
Sport
High risk activity
Contact and collision sport
High sporting level

36. Modifiers May influence investigation and management
May predict potential for prolonged or persistent symptoms
Multidisciplinary approach coordinated by a physician with specific expertise in management of concussion.

37. 6. Special Populations

38. Child and Adolescent Athlete
Adult recommendations can apply down to age 13
Below 13 require age appropriate symptom checklists and evaluation tool
child SCAT3 developed for this purpose
Include both patient and parent, teacher, school input.
Possibly use neuropsychological testing before symptoms resolve to help plan school management
must be developmentally sensitive, consider use of trained pediatric neuropsychologist
NOTE: Pediatric subcommittee has developed age-specific Child SCAT3
(Davis,  McCrea, G. Gioia, Purcell, Ellenbogen, C. Vaughan, Guskiewicz, Kutcher, Meeuwisse, McCrory)

39. Child and Adolescent Athlete
Consider age specific physical and cognitive rest issues
school attendance and activities need to be modified
No return to sport or activity until returned to school successfully
Symptom resolution may take longer, modifiers apply even more
More conservative RTP approach recommended:
Consider extending symptom-free period before starting return to play protocol
Consider extending length of the graded exertion protocol
Never return to play same day

40. Elite vs non-elite
All athletes should be managed the same regardless of level of participation
Available resources and expertise may determine management approaches
Consider cognitive evaluation in all organized high-risk sports regardless of age or level of performance

41. 7. Other Issues

42. Chronic traumatic encephalopathy (CTE)
Acknowledge potential for long-term problems in all athletes
CTE unknown incidence in athletic populations, cause/effect not yet demonstrated between CTE and concussions or exposure to contact sport

43. Prevention Protective equipment
Mouthguards have benefit in prevention oral injury, but no evidence of concussion reduction
Head gear and helmets show reduction in biomechanical forces, but have not translated to a reduction in concussion incidence
Helmets reduce head and facial injury in skiing and snowboarding and are recommended for alpine sports
Helmets reduce other forms of head injury (e.g. fracture) in cycling, equestrian, motor sports

44. Other Issues Rule changes Risk compensation Aggression vs violence
Consider where clear cut mechanism is implicated
To allow for effective off-field medical assessment (time and proper environment)
Risk compensation
Use of protective equipment may change behavior-especially child and adolescent
Aggression vs violence
Violent behavior that increases concussion risk should be eliminated
Promote fair play and respect

45. Preparticipation Evaluation
History:
Type of sport?
Previous symptoms of concussions?/length of recovery (recall unreliable from teammates, coaches)
Prior head, maxillofacial, spine injuries?
Non-sporting head injuries?
Type of player (“physical”?)
Ability to “take a hit”
Protective equipment (helmet age)
Opportunity to Educate!

46. Knowledge Transfer Education of athletes, parents, coaches
Awareness of concussion symptoms and signs
Fair play and respect
Role for web based resources, social media

47. Summary: What’s New? Evaluation on the “field of play”
Postural stability assessment
Timing of “rehabilitation”
The difficult concussion patient
Special populations
New Tools
Sport Concussion Assessment Tool revision (SCAT3)
Child SCAT3
Concussion Recognition Tool (CRT) for lay use

48. THANK YOU! Consensus Statement on Concussion in Sport
4th International Conference on Concussion in Sport held in Zurich, November 2012
© Concussion in Sport Group, 2013

49. Sport Concussion Assessment Tool 3rd Edition SCAT3

50. SCAT3 – 4 page layout 4. Patient Information 2. Scoring
3. Instructions
1. Sideline Assessment

60. Child Sport Concussion Assessment Tool Child SCAT3

61. Child SCAT3 -Differences
Child Maddocks questions
Symptom Scale child-specific
4 point rating scale
Parent rating of child’s symptoms
Orientation
no time of day
Concentration
start with 2 reverse digits
Reverse days of the week
Modified BESS
no single leg stance
Patient advice
return to school

69. Pocket Concussion Recognition Tool Pocket CRT

70. Pocket CRT

71. THANK YOU! Consensus Statement on Concussion in Sport
4th International Conference on Concussion in Sport held in Zurich, November 2012
© Concussion in Sport Group, 2013